Identifying substance misuse in primary care: TAPS Tool compared to the WHO ASSIST.

BACKGROUND: There is a need for screening and brief assessment instruments to identify primary care patients with substance use problems. This study's aim was to examine the performance of a two-step screening and brief assessment instrument, the TAPS Tool, compared to the WHO ASSIST. METHODS: Two thousand adult primary care patients recruited from five primary care clinics in four Eastern US states completed the TAPS Tool followed by the ASSIST. The ability of the TAPS Tool to identify moderate- and high-risk use scores on the ASSIST was examined using sensitivity and specificity analyses. RESULTS: The interviewer and self-administered computer tablet versions of the TAPS Tool generated similar results. The interviewer-administered version (at cut-off of 2), had acceptable sensitivity and specificity for high-risk tobacco (0.90 and 0.77) and alcohol (0.87 and 0.80) use. For illicit drugs, sensitivities were >0.82 and specificities >0.92. The TAPS (at a cut-off of 1) had good sensitivity and specificity for moderate-risk tobacco use (0.83 and 0.97) and alcohol (0.83 and 0.74). Among illicit drugs, sensitivity was acceptable for moderate-risk of marijuana (0.71), while it was low for all other illicit drugs and non-medical use of prescription medications. Specificities were 0.97 or higher for all illicit drugs and prescription medications. CONCLUSIONS: The TAPS Tool identified adult primary care patients with high-risk ASSIST scores for all substances as well moderate-risk users of tobacco, alcohol, and marijuana, although it did not perform well in identifying patients with moderate-risk use of other drugs or non-medical use of prescription medications. The advantages of the TAPS Tool over the ASSIST are its more limited number of items and focus solely on substance use in the past 3months.

Systematic review processes and the management of opioid withdrawal.

OBJECTIVE: To assess the diversity of research on the management of opioid withdrawal, identify sources of heterogeneity and provide a context for subsequent systematic reviews to establish evidence-based best practice. METHODS: References were identified through searches of multiple electronic databases and handsearching the reference lists of retrieved articles. The principal criterion for inclusion in the literature mapping process was that it be a study of an intervention intended to manage the process of opioid withdrawal. RESULTS: Of 218 references assessed, all participants were dependent on heroin in 41% and on methadone or l-alpha acetyl methadol (LAAM) in 24%. More than 17 different types of treatment approach were identified. Only 42% of references used a rating instrument to assess withdrawal severity and reported sufficient results to indicate the timing and magnitude of the peak and/or duration of withdrawal. The type of rating instrument used and the way in which results were reported varied enormously. A clear parameter for completion of detoxification was used for 37% of references. CONCLUSIONS: The capacity for rigorous systematic reviews of the management of opioid withdrawal is currently limited. There are multiple sources of heterogeneity that will need to be taken into account. IMPLICATIONS: The use of narrative reviews and observational studies are important complements to formal systematic reviews in the establishment of evidence-based practice in any area that combines aspects of psychology, behaviour, social context and medical treatment.

Therapeutic use of cannabis: clarifying the debate.

The debate regarding therapeutic use of cannabis is being confused by a lack of distinction between therapeutic and social use of cannabis. Separate consideration of therapeutic and social use would enable strategies to minimise any negative social impact of therapeutic use. For therapeutic use of cannabis to be considered on its own merits, greater emphasis needs to be placed on scientific evidence of therapeutic efficacy. At present the evidence is limited, it mostly relates to the use of synthetic cannabinoids, and much of it fails to compare cannabis with the best therapies available for the conditions of interest. Claims of therapeutic efficacy tend to be based on opinion and anecdote rather than the results of controlled studies. Further research is needed to clarify the potential therapeutic benefits, to enable claims of therapeutic use to be objectively assessed and to enable informed decisions to be made about the relative risks and benefits for any individual using cannabis for therapeutic purposes. Further research is required to clarify the efficacy of pure, synthetic cannabinoids compared to cannabis, the most effective route of administration, and the importance of delivering a known dose. The most likely value of cannabis is as an adjunct, rather than a replacement for, current medical approaches. The potential therapeutic benefits of cannabis will be greatest for those conditions where long-term cannabis use, with its attendant health risks, is not an issue and where the patient has the capacity to titrate dose against symptoms. There is sufficient evidence of potential therapeutic benefit to justify the facilitation of further research.

Improvements in retention rates and changes in client group with methadone maintenance streaming.

This study evaluated changes in client population and in retention rates following the introduction of a system of methadone maintenance streaming. A low intervention and low supervision stream was combined with two abstinence-orientated streams. Privileges of take-home doses and local pharmacy dose collection were contingent on successful participation in the abstinence-orientated streams. The clinic also modified policy to allow clients greater control over dose levels. The case notes of the first 100 clients entering the programme in the year prior to the changes (1991) and in the year following the changes (1993) were compared. The results showed a significant increase in retention rates. The demographic and heroin using histories did not change, but the newer programme attracted a greater proportion of clients with no previous history of methadone maintenance treatment. Mean clinic dose increased from 45 mg to 63 mg when clients were allowed to exert control over dose. These findings reveal improved outcomes in a public methadone maintenance programme as a result of policy changes designed to give clients greater control of their treatment.

In-patient treatment for the alcohol-dependent person: a public health perspective.

In accordance with public health principles, this paper is concerned with examining the individual, economic and political outcomes of in-patient treatment for alcohol dependence. It is argued that in-patient treatment for alcohol dependence per se is not justifiable at any of these levels, although in-patient treatment is justifiable for the treatment of the serious biomedical sequelae of dependence. For the alcohol-dependent person, the drinking, social, financial, psychological, work-related and health outcomes of out-patient treatment are as good as those for in-patient treatment; economically, out-patient programmes are more cost-effective than in-patient programmes; politically, moving the focus of treatment away from in-patient services is more likely to contribute to a cultural milieu which recognizes problems associated with alcohol dependence early and in their many different forms, rather than only by their long-term health consequences.

Injecting behaviour and risky needle use amongst methadone maintenance clients.

The injecting behaviour and risky needle use of a sample of 193 methadone maintenance clients was investigated. The majority of the sample (n = 116) reported injecting one or more drugs in the month prior to data collection. Compared with non-injectors, the injectors were slightly younger, had been on the methadone program for a shorter period of time, had lower methadone doses and more severe drug and legal problems. The injecting sub-group was examined in more detail by comparing those subjects whose injecting practices conformed to guidelines on minimizing risk of HIV transmission with those who, in the preceding month, made at least one injection contravening these guidelines and thus placed themselves at risk of contracting HIV. A greater proportion of these risky injectors were unemployed. Importantly, risky injectors had lesser knowledge of means of preventing the spread of HIV than safe injectors. It is concluded that the reduction of HIV transmission could be enhanced by improvements in methadone programs, particularly ensuring adequate dosing and high retention rates. Further, there is a need to improve knowledge with regard to what are safe and what are risky injecting practices and needle/syringe cleaning methods.

Drug and alcohol related health problems in primary care--what do GPs think?

OBJECTIVE: To examine knowledge, attitudes and beliefs of general practitioners (GPs) in the field of drug and alcohol related health problems. DESIGN: A cross-sectional survey in which self-completion postal questionnaires were sent to all identifiable GPs in the Adelaide metropolitan area. Non-responders received a reminder letter and second questionnaire. SETTING, PARTICIPANTS: The target population was doctors whose principal activity was general practice, or who were in training for general practice. MAIN OUTCOME MEASURES: Demographic and "practice characteristic" information on participants. Measures of knowledge, attitudes and beliefs regarding alcohol consumption, smoking and over the counter medication. RESULTS: The response rate was 59.8%. More responders than non-responders were affiliated with the Royal Australian College of General Practitioners. Alcohol consumption was perceived to be a more difficult issue than smoking to raise during consultations. GPs indicated that significant proportions of their patients were participating in hazardous drinking (mean estimate was 13.8% of patients), but only a third of respondents believed their effort in changing alcohol related behaviour would be effective. Sixty-one per cent of respondents identified hazardous daily levels of alcohol consumption for men consistent with National Health and Medical Research Council guidelines. In the case of women this figure was 42%. Longer reported appointment times were associated with greater reported levels of enquiry about alcohol consumption. CONCLUSIONS: New developments in medical training and systems of payment in general practice need to address both the pessimistic attitude of GPs in dealing with drug and alcohol related health problems, and apparent inconsistencies in defining hazardous alcohol consumption.